GW1-2022-10570_Well Construction - GW1_20221121

WZLL LV1NJ1KUU11UN_KLUUK0 For Internal Use ONLY:
This foray can be used for single or multiple wells
1.Well Contractor]Information:
BobbyW. Potts 14.WATERZz)NEs
. FROM To DESCWTIt N
Well Contractor Name ft it
NCWC 2028-A it ft
NC Well Contractor Certification Number 15.OUTER ING(for mnlfi ea edwdls OR LINER if ble
FROM TOI DIAMETER; I 7IOCE7aM MATERIAL
Ferguson's Well and Pump, LLC d ft71 ft t 'r` 12w
Company Name 16.INNER CASING OR G.4goodarmid dosed-loo
^ � � FROM TO DIAMETER. THICENFSS MATERIAL
2.Well Construction Permit#: �-!L�LI 1�! h p ,a_ ft ft i
List all applicable well const—fron permits(t.e.Cmmy,,State,3/ar sm,etc.) R ft irk.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER; SLOT smE I THicKNFSs I MATERIAL
ft ft in
❑Agricultural ❑ iipal/Public
❑Geothermal(Heating/Cooling Supply) B esidential Water Supply(single) ft ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 11L GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD a AMOUNT
Non-watter Supply Well:
❑Irri aa 0 ft 20 n Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACKN e
FROM I TO MATERIAL EMPLACEMENT AXTHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft fC -
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
2(L DRILLING LOG:atta&:addifiwAsheetsif 0
❑Geuthetmal(Closed Loup) ❑Tracer FROM TO DESCRIPTION color,hardy sWlh'm t ffi etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) Q ft 7 ft
ft ft
4.Date Well(s)Completed: jl/.C,� Well IDk ft ft
Sa.Well Location: , 2 tt
29'
ft ft
Facility/0wneriVame Facility ID#(if applicable) ft ft
Physical Address,City,and Zip & " F a ;1 .•`
21.REMAPJM
.1e150 n Goa 4 4 1 20Z
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification r�
in(»tY° L
(if wall field one 1aUlong is sufficient) ,.J
Sigffiture . Q Well ntrac r
6.Ty(are)the well(s): 2Krminent or ❑Temporary By,signing this form,I hereby certify that the wefl(s)was(were)constructed in accordance
�,K�/ with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 JEW Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 6o copy of this record has been provided to die well owner.
If this is a repair,f l out known well construction aVrormation and erphun the nature ofthe
repair rider#21 rmw*s section or on the back of dusform 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For mutiple vyecftm or non-water supply wells ONLY with the same eotrstrudiat you can
submitonefornr SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 !S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if,fifferad(ec=Vk 3@200'and 2Q100D construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Maid Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in-) 24b.For Iniedion Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
11 Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground]InjectioltControi Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Iniectioae Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: CIIIOfIne Amount j pZ, completion of well construction to the county health department of the county
where constructed-
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013